Meeting News

In CTO PCI, prior CABG may portend poor outcomes

Emmanouil S. Brilakis

Among patients who underwent chronic total occlusion PCI, those with prior CABG had worse outcomes including higher rates of in-hospital morality, MI and coronary perforation compared with those without prior CABG, according to findings from a meta-analysis on the program at the American College of Cardiology Scientific Session.

These findings were also published in JACC: Cardiovascular Interventions.

“Prior CABG patients who require CTO PCI are more likely to be complex and require advanced techniques such as the retrograde approach for successful recanalization,” Emmanouil S. Brilakis, MD, PhD, FSCAI, director of the Center for Complex Coronary Interventions at Minneapolis Heart Institute, told Healio. “Such procedures may be best done by experienced operators and centers.”

Data from observational studies

Michael Megaly, MD, MS, cardiology fellow at Minneapolis Heart Institute, and colleagues analyzed data from 8,131 patients from four observational studies that compared in-hospital outcomes after CTO PCI in patients with or without prior CABG. Of these patients, 2,163 patients had prior CABG (mean age, 68 years) and 5,968 did not previously undergo the surgery (mean age, 64 years).

Compared with patients without prior CABG, those who previously underwent the surgery had longer fluoroscopy time (mean difference, 16.9 minutes; P < .001; I2 = 95%), lower technical success (80.7% vs. 86.5%; OR for procedural failure = 1.66; 95% CI, 1.42-1.94; I2 = 24%) and higher contrast use (mean difference, 16.4 mL; P < .001; I2 = 49%).

#
Emmanouil S. Brilakis, MD, PhD, FSCAI, director of the Center for Complex Coronary Interventions at Minneapolis Heart Institute.

Patients with prior CABG had a higher incidence of coronary perforation (7.3% vs. 4.9%; OR = 2.07; 95% CI, 1.49-2.86; I2 = 50%), in-hospital mortality (0.8% vs. 0.3%; OR = 2.77; 95% CI, 1.43-5.39; I2 = 0%) and MI (1.4% vs. 0.5%; OR = 2.46; 95% CI, 1.46-4.15; I2 = 1%) compared with those without prior CABG. These patients also had a lower incidence of cardiac tamponade (0.1% vs. 0.8%; OR = 0.19; 95% CI, 0.04-0.87; I2 = 11%).

Prior and no prior CABG groups had similar incidence of vascular (1.7% vs. 1.2%; OR = 1.39; 95% CI, 0.84-2.31; I2 = 0%) and cerebrovascular complications (0.3% vs. 0.3%; OR = 1.51; 95% CI, 0.49-4.66; I2 = 15%).

“Despite the slightly lower success rates from previous CABG patients, the overall message is positive,” Brilakis said in an interview. “The vast majority of these complex patients can be successfully treated with significant improvements in their quality of life. We have also come a long way in understanding the specific challenges associated with treatment of those patients as well as potential complications such as loculated tamponade that can be a catastrophic complication in such patients. We now know to treat early a perforation if it happens in the previous bypass patient so as to avoid loculated tamponade. We still, however, need more operators to develop the skills and infrastructure to offer the needed treatments for these complex patients.”

Further research

Additional research is needed in this area, Brilakis said.

“One is on educational approaches to enable more operators to perform this complex procedure with high success and low complication rates,” he told Healio. “The second is new devices and techniques that will allow easier, safer and more successful CTO PCI in previous CABG patients.” – by Darlene Dobkowski

References:

Megaly M, et al. Abstract 1151-011. Presented at: American College of Cardiology Scientific Session; March 28-30, 2020 (virtual meeting).

Megaly M, et al. JACC Cardiovasc Interv. 2020;doi:10.1016/j.jcin.2019.11.033.

Disclosures: Brilakis reports he receives consultant/speaking honoraria from Abbott Vascular, American Heart Association, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation, Cardiovascular Systems Inc., Elsevier, GE Healthcare, InfraRedx, Medtronic, Siemens and Teleflex; receives research support from Regeneron and Siemens and is a shareholder of MHI Ventures. Megaly reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Emmanouil S. Brilakis

Among patients who underwent chronic total occlusion PCI, those with prior CABG had worse outcomes including higher rates of in-hospital morality, MI and coronary perforation compared with those without prior CABG, according to findings from a meta-analysis on the program at the American College of Cardiology Scientific Session.

These findings were also published in JACC: Cardiovascular Interventions.

“Prior CABG patients who require CTO PCI are more likely to be complex and require advanced techniques such as the retrograde approach for successful recanalization,” Emmanouil S. Brilakis, MD, PhD, FSCAI, director of the Center for Complex Coronary Interventions at Minneapolis Heart Institute, told Healio. “Such procedures may be best done by experienced operators and centers.”

Data from observational studies

Michael Megaly, MD, MS, cardiology fellow at Minneapolis Heart Institute, and colleagues analyzed data from 8,131 patients from four observational studies that compared in-hospital outcomes after CTO PCI in patients with or without prior CABG. Of these patients, 2,163 patients had prior CABG (mean age, 68 years) and 5,968 did not previously undergo the surgery (mean age, 64 years).

Compared with patients without prior CABG, those who previously underwent the surgery had longer fluoroscopy time (mean difference, 16.9 minutes; P < .001; I2 = 95%), lower technical success (80.7% vs. 86.5%; OR for procedural failure = 1.66; 95% CI, 1.42-1.94; I2 = 24%) and higher contrast use (mean difference, 16.4 mL; P < .001; I2 = 49%).

#
Emmanouil S. Brilakis, MD, PhD, FSCAI, director of the Center for Complex Coronary Interventions at Minneapolis Heart Institute.

Patients with prior CABG had a higher incidence of coronary perforation (7.3% vs. 4.9%; OR = 2.07; 95% CI, 1.49-2.86; I2 = 50%), in-hospital mortality (0.8% vs. 0.3%; OR = 2.77; 95% CI, 1.43-5.39; I2 = 0%) and MI (1.4% vs. 0.5%; OR = 2.46; 95% CI, 1.46-4.15; I2 = 1%) compared with those without prior CABG. These patients also had a lower incidence of cardiac tamponade (0.1% vs. 0.8%; OR = 0.19; 95% CI, 0.04-0.87; I2 = 11%).

Prior and no prior CABG groups had similar incidence of vascular (1.7% vs. 1.2%; OR = 1.39; 95% CI, 0.84-2.31; I2 = 0%) and cerebrovascular complications (0.3% vs. 0.3%; OR = 1.51; 95% CI, 0.49-4.66; I2 = 15%).

“Despite the slightly lower success rates from previous CABG patients, the overall message is positive,” Brilakis said in an interview. “The vast majority of these complex patients can be successfully treated with significant improvements in their quality of life. We have also come a long way in understanding the specific challenges associated with treatment of those patients as well as potential complications such as loculated tamponade that can be a catastrophic complication in such patients. We now know to treat early a perforation if it happens in the previous bypass patient so as to avoid loculated tamponade. We still, however, need more operators to develop the skills and infrastructure to offer the needed treatments for these complex patients.”

PAGE BREAK

Further research

Additional research is needed in this area, Brilakis said.

“One is on educational approaches to enable more operators to perform this complex procedure with high success and low complication rates,” he told Healio. “The second is new devices and techniques that will allow easier, safer and more successful CTO PCI in previous CABG patients.” – by Darlene Dobkowski

References:

Megaly M, et al. Abstract 1151-011. Presented at: American College of Cardiology Scientific Session; March 28-30, 2020 (virtual meeting).

Megaly M, et al. JACC Cardiovasc Interv. 2020;doi:10.1016/j.jcin.2019.11.033.

Disclosures: Brilakis reports he receives consultant/speaking honoraria from Abbott Vascular, American Heart Association, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation, Cardiovascular Systems Inc., Elsevier, GE Healthcare, InfraRedx, Medtronic, Siemens and Teleflex; receives research support from Regeneron and Siemens and is a shareholder of MHI Ventures. Megaly reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    See more from American College of Cardiology